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First published January 20, 2021. Original post here.

“The key to working with behavioral health clients,” a clinical supervisor told me over 30 years ago, “is asking about the past losses they’ve suffered and exploring whether they mishandled them.”

He was a loss zealot, a mourning maven. He walked clients through guided imagery exercises of standing beside their loved one’s casket. To him, unresolved bereavement was not just a major psychological force in the lives of most people, but a kind of unifying theory underlying all psychopathology and behavioral health treatment.

These were the olden days when Elisabeth Kubler-Ross’ On Death and Dying and Therese Rando’s Grief, Dying and Death—Clinical Interventions for Caregivers were grad school fare and Judith Viorst’s Necessary Losses, about normal development’s inherent losses (e.g., growing up and leaving home, launching our kids), was a national best-seller.

In my supervisor’s mind, most clients suppressed healthy grieving and consequently had chronic symptoms of anxiety, depression and anger. By reinitiating their long-stalled mourning process, he believed we could help them more fully grieve and then live symptom-free with a greater awareness of life’s preciousness and death’s proximity.

In the decades since, we have all gone on to become trauma-informed and resiliency-minded practitioners. But my supervisor’s words recently have been echoing loudly in my head. It’s not news that the pandemic’s death and debility, isolation and unemployment are causing widespread suffering.

In my part-time teletherapy practice outside Philadelphia, several of my clients have been directly affected by COVID. A 78-year-old, African-American man succumbed to the virus last month. An 80-year-old woman watched her husband die at home, gasping for breath in their bed. A 37-year-old woman said goodbye to her mother via FaceTime on an ICU nurse’s phone.

Every patient I see, however—just like nearly every patient you see, I imagine—has had routines upturned, social lives disrupted, and relationships strained. Grief about the losses they’ve experienced of their sense of safety, freedom of movement, and community connectedness are a spur to their increased anger, helplessness, hopelessness, depression and anxiety.

Isn’t it the right time then to take up my old supervisor’s cudgel? COVID is still wreaking havoc. It will take years to address the emotional damage it is causing, even after the pandemic finally ends. If we do place coping with loss closer to the center of promoting wellness, then how would that change the way we practice clinically? It would require three steps:

Screening

In primary care, we screen routinely for, among many other things, domestic violence, depression and wearing bicycle helmets. At each clinical encounter, we should now screen for unresolved loss as well. A good question might be: “Many of us have suffered multiple losses during the past year. What losses of people, activities, jobs or a sense of safety have you experienced and how have they affected you?” That would be the conversation-starter that many people need who are otherwise too ashamed to mention their grief during a healthcare visit.

Education

It’s a cliché that Americans, ever future-oriented, avoid thinking or talking about death. It’s equally true that most of us underestimate the impact of grief on our well-being or the length of time we need to heal. It has always shocked me whenever I’ve encountered clients who believe they can lose a spouse or a parent one week and then bounce back fully the next with the rationalization they must be “strong” for others. We should be providing education to normalize grief for all COVID-related losses, not just death, and then help our patients accept it will be months, if not years, before they cry their share of tears, come to terms with their losses, and integrate them, slowly and painfully, into their lives.

Meaning

Every cognitive behavior or narrative therapist knows that mental wellness hinges on the positive or negative meanings we attribute to our experiences and perceptions. The meanings we make of COVID losses, too, will govern how well we cope long-term. Do we view the pandemic as plague or punishment from God or a test of our fortitude? Do we see being cooped up as a form of entrapment or an opportunity for greater gratitude for home and hearth. Do we sink under the barrage of America’s COVID deaths or rise to a greater valuing of life?

Meaning is wrought in various ways. Many authors, including family therapists Evan Imber-Black and Froma Walsh, have written extensively about the use of rituals to help give loss more positive meaning. Rituals are ways to express our emotions in a circumscribed, community-sanctioned form, standing shoulder to shoulder with commiserating supporters. Those include cultural/religious rituals, such as wakes, shivas, and home-goings, and those rituals we create in our own families—e.g., eating the favorite meal or visiting the treasured fishing hole of our loved ones.

What would a COVID-related loss ritual look like? A mass mask-burning might be nice. Telling the stories publicly of the vulnerable people who died is essential. For healthcare professionals, it could include Schwartz Rounds or a memorial tree-planting on the grounds of our hospitals, primary care offices and mental health clinics. We need to erect markers in our lives to help us grieve our losses and remember how connected this pandemic has proved we are through contagion and compassion.